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Rhinoplasty: Step-By-Step

Rhinoplasty is an intricate facial cosmetic procedure that requires a comprehensive understanding of the underlying anatomy and an artistic interpretation of an individual’s characteristics to give a natural looking result. The goal of rhinoplasty is to improve the appearance of your nose with respect to your individual facial appearance, body type and ethnicity. Depending on the shape and size of a patient’s nose this can involve refinement of different parts of the nasal architecture. The key for a natural looking result is refinement surgery that is conservative and avoids an unnatural ski slope or pinched appearance. These principal steps in rhinoplasty surgery are as follows however the surgical technique is tailored to the individual:
  • Marking of the nose, a discrete mark is placed on the under surface of your nose. Other marks may be made dependent on the rhinoplasty surgery including marking of the nostrils for alar reduction, and the chin area for chin augmentation
  • Anaesthesia is administered by several different means for rhinoplasty, principally sedative anaesthesia or general anaesthesia. In addition local anaesthesia with adrenaline is injected into the nose, this aids the surgery by reducing bleeding and increasing the ease of surgery. See link for Anaesthesia Options.
  • Incision: which maybe either through the skin (open or transcutaneous technique) or through the lining of the nose (closed or intranasal technique) is completed.
  • Tip Refinement: The tip of the nose consists of two principal cartilages called the lower lateral cartilages. In a large or bulbous tip these cartilages are shaped, sculpted and re-stitched together to give the tip of the nose a more defined appearance. Often there are natural asymmetries or uneven shapes in the cartilage in the tip of the nose that can lead to a widened irregular and asymmetrical tip. With open rhinoplasty the cartilages on the right and left sides can be measured to a millimetre to make even and with specific stitches the shape made more even and refined.

oblique Lower lateral cartilages - figure

The before photo on the left shows a higher left cartilage (green arrow) and a lower right cartilage (red arrow), the after photo shows a nasal tip that is smaller, more refined and symmetrical.
The before photo on the left shows a higher left cartilage (green arrow) and a lower right cartilage (red arrow), the after photo shows a nasal tip that is smaller, more refined and symmetrical.
  • Drooping Nasal Tip: the tip is elevated and rotated, depending on the amount of droop this is corrected with a combination of elevation of the tip cartilages and refinement of the lowest cartilage of the nose, termed the caudal nasal septum.

Nose Tip Elevation - pic

  • Upturning nose or short nose: The tip is counter-rotated downwards to lengthen the nose and reduce the upturning nose. With revision rhinoplasty additional graft tissue may be required to lower the nasal tip.
  • A Nasal Bridge Hump or Bump defines the size and shape of the nose and may be elevated as a hump, or depressed as a consequence of collapse of the nose through trauma or over surgical resection. The nasal hump of the nose is reduced in size by reduction of both the cartilage (lower two thirds) and bones of the nose (upper one third). In addition, support of the bridge is often completed with the use of cartilage grafts these support the nose long-term and maintain functional breathing. A depressed or collapse of the bridge of the nose requires augmentation of the cartilages in the bridge of the nose, often this requires graft tissue to support the nose. The graft tissue may be taken from the patients’ septal cartilage (Primary Rhinoplasty), in other cases this must be taken from elsewhere including ear cartilage or harvested costal cartilage.  Dr. De Silva prefers to use a patient’s own septal cartilage where possible as this is the closest to a patient’s own cartilages, however in cases where this has already been removed, other alternatives are necessary.

Nasal Bump - figureNasal Bump Reduction - figureNasal Bump result - pic

  • Breathing through the nose is an important function of the nose and rhinoplasty often narrows the airway passages that can reduce breathing. To improve the airways and maintain breathing, Dr. De Silva frequently uses graft tissue to support the structure of the nose long-term.
  • Septoplasty is a common procedure that is combined with rhinoplasty. The septum is a cartilage plate that lies in the very centre of the nose (see the figure below), the septum is a wall of tissue that separates the right and left nostrils and airway. A deviated septum is commonly without symptoms, however if severe it may cause a crooked nose and difficulty in functional breathing, it is an important consideration in rhinoplasty to ensure that the breathing is not affected by rhinoplasty. In addition the septal cartilage may be used for graft material which Dr. De Silva uses for supporting the nose and enhancing the fine definition of the nasal tip. The septal deviation should be corrected during the cosmetic rhinoplasty to give a good long-lasting and effective result. Dr. De Silva performs septoplasty in 30% of cosmetic rhinoplasties.

      Septoplasty, septum - figure

  • Osteotomies also know as Breaking the Nose. Narrowing the base of the nose, termed osteotomy, are required in most rhinoplasty surgeries to give the nose an improved shape and narrower nasal bridge.  Dr. De Silva utilises electrocautery to minimise bleeding and to make a pocket incision for the osteotome instrument to be used. The nasal bones that make up approximately the upper third of the nose are individually broken with special instruments that result in a controlled and planned break. The nasal bones are then brought together and pressure applied to minimise bleeding. Osteotomies can be performed through the skin or hidden within the inside of the nose, Dr. De Silva prefers to use hidden incisions where possible as this avoid unnecessary scarring of the skin.
  • Dr. De Silva then reassess the nose, as changing one parameter of the nose inherently has an impact on the nasal bridge and tip. Further refinement of the nasal bridge is completed until it is straight and refined (all men) or has a small tip just before the nasal tip, termed the supra-tip break (some women depending on both ethnicity and shape of face).
  • Additional grafts may be required to increase the definition, projection of the nose, these are sculpted to an individual’s unique nasal characteristics. Dr. De Silva uses different types of graft tailored to an individual’s specific needs, these include: Strut supporting grafts, Spreader grafts, alar grafts, batten grafts, cap and tip grafts, dorsum grafts and shield grafts.
  • Closure of the mucosal inner lining of the nose is completed with dissolvable stitches.
  • Sutures/Stitches: Closure of the skin beneath the nose with small stitches, these are removed 1-week after surgery.
  • Alar/ Nostril Reduction: Narrowing of the nostrils that are indicated for some patients. This surgery requires both precision and delicacy to hide the incisions on the inside of the nostril and maintain adequate functional breathing through the nose.

 Alar Reduction - figure

  • Nasal Packing: Some surgeons advocate the use of packing within the nose, Dr. De Silva rarely applies packing within the nose as the septum is individually repaired with stitches and patients often find packing of the nose uncomfortable.
  • Splint: A plaster of paris or Denver splint is applied to the bridge of the nose. The splint holds the position of the bone in place as the nose heals over the first week after surgery and reduces swelling.
  • Tape: A fine skin coloured Micropore tape is applied over the surface of the nasal splint and provides additional support to the nasal tip. 

 

Complex Rhinoplasty Techniques By Dr. De Silva 

What is a nasal graft?

A graft is defined as any tissue or material that can be from one portion of the body which is placed in another, and is used to improve the results from rhinoplasty surgery. Dr. De Silva uses nasal grafts to improve the aesthetic appearance of the nose by increasing definition, improving symmetry or lifting the nose, in addition to improving functional breathing. Types of grafts include:

  • Strut Grafts: These grafts add extra strength and stability to the lower part of the nose, they can improve symmetry and reduce twisting of the nose in revision rhinoplasty, in addition to reducing the size of a nose by lifting the nasal tip. Dr. De Silva frequently uses patient’s own septal cartilage to make a customised strut graft where the natural cartilage is weak, this ensures that your rhinoplasty will have sufficient support and stability for many decades after the surgery.
  • Spreader Grafts: Spreader grafts are added to the middle portion of the patient’s nose and can be used to improve symmetry, reduce indentations or twisting of the nose. They are often used in revision rhinoplasty procedures to improve functional breathing. They are not suitable for all rhinoplasty as they do widen the bridge of the nose, Dr. De Silva finds that in most patients, a narrower nose has a more refined and artistic appearance. Spreader grafts are placed between the septum and upper lateral cartilage and can be inserted with an open approach or closed endonasal technique.
  • Onlay Grafts & Cap Grafts: These grafts are often used in rhinoplasty techniques to improve tip definition and refinement. These grafts are customised based on an individual ethnicity and skin thickness, Dr. De Silva uses these grafts more commonly in  ethnic rhinoplasty to increase nasal tip definition and refinement.
  • Alar Rim & Batten Grafts: These Grafts are often used to prevent nostril collapse (termed nasal valve collapse), caused when there is a weakness in the nostril sidewall particularly in deep inspiration (inward breath). In addition they can be important in repairing damage to the nostrils from previous surgery, and used to improve nostril asymmetry,  to correct alar retraction or to correct a “pinched” nasal tip. Alar batten grafts may be harvested from the septum or ear, Dr. De Silva prefers to use ear cartilage as the natural curve of ear cartilage can be used optimally to follow the natural curve of the nostrils.

What is a nasal implant?

A nasal implant is either a synthetic biocompatible or a biological material processed through regulatory approved methods to be used as implants. Examples of synthetic implants are medpor, silicone, or Gor-tex. Examples of biologically derived implants are irradiated rib cartilage from a rib bank or Alloderm (collagen like soft material used to thicken nasal skin). Biological implants may absorb (shrink) to some extent with time but synthetic implants do not shrink or change with time. Synthetic implants are used and have been tested not just for cosmetic or reconstructive purposes in the nose but are used for reconstructive purposes in other parts of the face and body with a long record of follow up.

Why not use natural “grafts” all the time?

Natural grafts refers to material taken from ones own body which includes your septum (hidden cartilage that lies between the right and left sides of your nose, ear cartilage and rib cartilage. Benefits of using natural grafts are that they are taken from your own body. Natural grafts are not always available in revision rhinoplasty as previous surgery has removed the grafts, in ethnic rhinoplasty (some ethnicities have relatively small septal cartilages) and specific indications the shape or size of the grafts may be inadequate to achieve the best result. Natural “grafts” sometimes absorb or deteriorate with time, whereas, synthetic implants do not deteriorate. Rib, septum, and ear cartilage have varying degrees of absorption with time. Natural “grafts” sometimes warp (twist) over time and rib cartilage has the higher risk of warping with time. Dr. De Silva does not use patients own rib cartilage due to unwanted risks and potential for injury from damage to the lung or chest wall during surgery, the potential risk that this type of graft may dissolve and bend long-term and the long surgical time required.

Dr. Julian De Silva uses both natural grafts and synthetic implants and sometimes uses a combination of both to achieve the best outcome with maximal support and definition.

Who is a good candidate for nasal implant use?

Dr. Julian De Silva recommend  that healthy non-diabetic patients who are non-smokers are the best candidates for nasal implant use because they are the least likely to encounter an infection and achieve an excellent outcome. Patients with thicker skin also tend to be better suited for certain implants as the thicker skin provides better coverage and protection of the implant. Patients with thin skin may require additional techniques that include a thickening graft of Alloderm or temporalis fascia between the synthetic implant and the patient’s skin. Patients that need implants the most such as Afro-Caribbean and Asians tend to have thick skin.

Which patients are not good candidates for implant use?

Dr. Julian De Silva believes that patient selection is very important in planning complex rhinoplasty surgery with synthetic implants to obtain successful long-term results and minimise the risk of infection, movement or extrusion. Dr. De Silva does not recommend using implants in smokers, patients who use illicit drugs in the nose such as cocaine, diabetic patients, or patients with a reduced immunity status. Smokers tend to have a higher risk of infections of the implants and subsequent need for removal.

Why use nasal implants?

Nasal implants are used to correct nasal deficiencies in the dorsal area (bridge of nose) as well as many other areas of the nose including the tip or the sides. They may be used to provide additional height or definition to a flat nose or nasal tip in an ethnic Middle Eastern, African, Afro-Caribbean or Asian rhinoplasty. In additionthey may be used to correct a collapse on one side of the nose to make it look straighter. An implant may also be used to support a drooping nasal tip. Implants are frequently used in revision rhinoplasty where too much cartilage was removed from a previous rhinoplasty.

How are the implants shaped?

Nasal implants come in varying sizes and shapes for the tip and dorsum (bridge of the nose). However, Dr. Julian De Silva believes it is important to sculpt and customize the implant to the patient and uses prevision instrument shape and sculpt the nasal implant. Using technology sculpting the implants is precise and eliminates sharp edges.

Why not use one’s own (autogenous) material in the nose all the time?

Dr. Julian De Silva, often utilses a patient’s own cartilage (termed autogenous grafts) in rhinoplasty either from the septum or ear or from other sources. However, commonly in ethnic rhinoplasty, the patient’s own cartilage is too small and weak to provide the needed support or definition to the bridge and tip of the nose. Sometimes Dr. De Silva uses autogenous cartilage grafts in combination with artificial implants to give the needed support and definition. Also sometimes in severe saddle nose deformities in revision rhinoplasty or in traumatic noses, one’s own cartilage is not thick enough to give the needed height in a nose. In Asian and black rhinoplasty, the patient’s septum and ear cartilage tends to be thin and weak and inadequate for the support and definition needed in these noses to support their thicker skin. One’s own cartilage can also absorb (shrink) with time and may warp as well with time, whereas synthetic implants do not absorb or warp.

What kind of implants does Dr. De Silva use in patients requiring Revision Rhinoplasty?

Dr. De Silva’s first choice of graft tissue is using a patient’s own natural cartilage to make graft tissue, this includes the patient’s own septal cartilage (from the patients’ own nose or patients’ ear cartilage). Dr. De Silva also uses irradiated cartilage (harvested from a cadaver in the USA) in some cases, especially in revision rhinoplasty procedures in which the nasal framework needs to be reconstructed. Irradiated cartilage becomes necessary when ear cartilage won’t suffice (because stronger cartilage is needed) and the patient has no extra septal cartilage to harvest. It is particularly useful for reshaping the nasal bridge (repair of previous rhinoplasty resulting in “Ski slope” or scooped nasal bridge) and supporting the nasal tip.

What kind of implants does Dr. De Silva use in patients in ethnic rhinoplasty with patient’s with thick skin?

Dr. De Silva prefers to use custom-sculpted Medpor implant in thick skin ethnic noses. The Medpor integrates better than silicone and Dr. De Silva customizes the implant during the procedure with his microburrs and dermabrading system to fit into your nose creating smooth rather than visible sharp or pointy edges. This customized implant integrates by tissue ingrowth into the implant and therefore stabilizing it. The need for an implant In ethnic noses arises when there is poor quality cartilage in the septum and ear characteristic of ethnic patients’ cartilage – though there are some cases where Dr. De Silva has used patient’s own cartilage successfully.

 

For more information on Rhinoplasty, click on the following links:

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